HOSPITAL CHART REVIEW FORM - POLST
OR HOSPITAL CHART REVIEW FORM
1. Today’s Date _________________________
2. Age in Years ________
3. Gender
( Female ( Male
4. Race/Ethnicity:
( White ( African American/Black ( Native Hawaiian/Pacific Islander ( Asian ( American Indian/Alaskan Native ( Hispanic ( Other ( not available
5. Education
( No Schooling ( 8th Grade/less ( 9 – 11th grades
( High School ( Technical/trade school ( some college
( Bachelor’s degree ( Graduate degree ( not available
6. Discharge destination
( Bethany St. Joseph’s ( Bethany Riverside ( Hillview
( St. Joseph’s ( Onalaska Care ( Mulders
( Lakeview ( Rolling Hills ( Morrow Home
7.Admission/Discharge:
a. Primary reason for hospitalization_____________________________________
b. Reason for discharge to nursing home
□ rehabilitation □ long term care □ other ___________
c. Is this a new discharge to a nursing home? □ yes □ no
d. Did the resident have a POLST at admission to the hospital? □ yes □ no
If the resident had a POLST at admission, was the POLST changed at discharge? ( yes ( no ( not applicable
8. Primary service admitted to:__________________________________________
Discharge Service: _________________________________________________
Date of admission_________________ Date of Discharge __________________
HOSPITAL PREFERENCES, ORDERS, & LIFE-SUSTAINING TREATMENTS
9. PREFERENCES: Is there evidence of a discussion about treatment preferences in the chart at discharge: □ yes □ no
If yes, describe:
|Date of Discussion |Staff involved? Identify. |Patient/family involved? Identify. |Was surrogate authorized? If so, |
| | | |describe role. |
| | | | |
| | | | |
| | | | |
a. Where is this documented? ______________________________________
b. Who documented the discussion? _________________________________
c. Length of discussion
□ 0-15 min. □ 15-30 min. □ 30-45 min □ no time listed
d. What was discussed? Please describe treatment preferences or plans.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
10. a. What, if any, advance directive forms are present in the chart? (Check all that apply)
❑ Advance directive/living will (circle type used and indicate date of document)
o LaCrosse Respecting Choices POAHC _____/_____/_______ Date
o Addendum to POAHC _____/_____/_______ Date
o Statement of Treatment Preference form _____/_____/_______ Date
o Wisconsin Statutory POAHC _____/_____/_______ Date
o Wisconsin Declaration to Physicians or
other Living Will _____/_____/_______ Date
❑ Designated Decision-maker (named by resident) _____/_____/_______ Date
❑ Legal Guardian _____/_____/_______ Date
❑ Other (describe) __________________________ _____/_____/_______ Date
❑ No form present
b. Who is making decisions at this point in time?
❑ Patient
❑ Healthcare Agent
❑ Legal Guardian
❑ Designated Decision-maker
❑ Next of kin
❑ Other:__________________________
11. Document all treatment preferences in the table below. (See advance directive)
| | |
|IF I AM CLOSE TO DEATH: |IF I AM PERMANENTLY UNCONSCIOUS/PERISTENT VEGETATIVE STATE: |
|I want feeding tubes/artificial nutrition and hydration. |I want to receive tube feeding |
|I want tube feedings only as my physician recommends |I want tube feeding only as my physician recommends |
|I do not want feeding tubes/artificial nutrition and hydration |I do not want tube feeding |
|No preference indicated |No preference indicated |
| | |
|I want any other life support that may apply |I want any other life support that may apply |
|I want life support only as my physician recommends |I want life support only as my physician recommends. |
|I want NO life support |I want NO life support |
|No preference indicated |No preference indicated |
|KIDNEY DIALYSIS |VENTILATOR SUPPORT |
|( I do want kidney dialysis |( I do want ventilator support |
|I do not want kidney dialysis |I do not want ventilator support |
|No preference indicated |No preference indicated. |
| | |
|RESUSCITATION (preferences, not orders) |LOSS OF ABILITY TO RELATE TO SELF, OTHERS AND ENVIRONMENT |
|( I do want cardiac resuscitation |I do not want CPR |
|I do not want cardiac resuscitation |I do not want antibiotics |
|I want CPR under certain circumstances as MD recommends |I do not want a feeding tube, artificial hydration and nutrition |
|No preference indicated |No preference indicated |
|ANTIBIOTICS |TRANSFUSION |
|( I do want antibiotics |( I do want transfusion |
|I do not want antibiotics |I do not want transfusion |
|No preference indicated |No preference indicated |
|PAIN AND SYMPTOM CONTROL IF EFFORTS TO PROLONG LIFE ARE STOPPED |HOSPITALIZATION |
|I want to be kept comfortable even if it risks my dying sooner |( I do want ____________________ |
|No preference indicated |( I do not want _________________ |
| |( No preference indicated |
|Agent authority to admit me to a nursing home or community-based |Agent authority to order the withholding or withdrawal of feeding tube|
|residential facility for the purpose of long-term care: |and IV hydration: |
|( Yes |( Yes |
|No |No |
| |
|OTHER PREFERENCES |
12. ORDERS RE LIFE-SUSTAINING TREATMENT: Document all medical orders written in the medical chart in the table below.
|TREATMENT CATEGORY | |WRITTEN ORDERS |DATE OF ORDER |
| |CHECK | | |
| |BOX | | |
|Resuscitation/ | |Full Code | |
|Medical | | | |
|Intervention | | | |
| | |O-DNR | |
| | |O-DNR/DNI | |
| | |P-DNR | |
|Other Orders (specify) | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
13. TREATMENTS: Document life-sustaining treatments below.
|TREATMENT PROVIDED |Date(s) of occurrences |Treatments Provided & |
| | |Other Relevant Information |
|Resuscitation: |1)____________ | |
| |2)____________ | |
|EMS visit with/without transport |1) ____________ |1) ____________ |
|(indicate treatments provided by EMS): |2) ____________ |2) ____________ |
| |3) ____________ |3) ____________ |
| |4) ____________ |4) ____________ |
|Emergency Department Visit without |1) ____________ |1) ____________ |
|hospitalization (indicate treatments provided in |2) ____________ |2) ____________ |
|ED): |3) ____________ |3) ____________ |
| |4) ____________ |4) ____________ |
|Hospitalization: |1) ____________ | |
| |2) ____________ | |
|Surgery: |1) ____________ | |
| |2) ____________ | |
|Transfusion: |1) ____________ | |
| |2) ____________ | |
| |3) ____________ | |
| |4) ____________ | |
|Intubation: |1) ____________ | |
| |2) ____________ | |
| |3) ____________ | |
| |4) ____________ | |
|Dialysis: |1) ____________ | |
| |2) ____________ | |
| |3) ____________ | |
| |4) ____________ | |
|Antibiotics: |1) ____________ | |
| |2) ____________ | |
| |3) ____________ | |
| |4) ____________ | |
|Feeding Tubes: |1) ____________ | |
| |2) ____________ | |
| |3) ____________ | |
| |4) ____________ | |
|IV Fluids: |1) ____________ | |
| |2) ____________ | |
| |3) ____________ | |
| |4) ____________ | |
|Chemotherapy: |1) ____________ | |
| |2) ____________ | |
| |3) ____________ | |
| |4) ____________ | |
|Ventilator/Respirator: |1) ____________ | |
| |2) ____________ | |
| |3) ____________ | |
| |4) ____________ | |
14. At discharge are there orders for life-sustaining treatment out in the community?
□ yes □ no
If yes, what type of orders?
□ Wisconsin DNR order form/bracelet _____/_____/_______ Date
□ POLST (Please document orders found on POLST below)
a. Is document signed? □ yes □ no
b. Is document dated? □ yes □ no
If yes, date signed: _____/_____/_______ Date
c. Is there a resident/surrogate signature on back? □ yes □ no
d. What parts of document have been completed?
□ A □ B □ C □ D □ E
15. POLST ORDERS AT DISCHARGE
|TREATMENT CATEGORY | |WRITTEN ORDERS |DATE OF ORDER |
| |CHECK | | |
| |BOX | | |
|A. Resuscitation | |DNR/DNAR | |
| | |Full Code | |
|B. Medical Interventions | |Comfort measures only….allow a natural death to occur | |
| | |Do not hospitalize | |
| | |Limited/advanced treatments | |
| | |Full treatment | |
|C. Antibiotics | |No antibiotics | |
| | |No IM/IV antibiotics | |
| | |Antibiotics | |
|D. Artificial Nutrition and | |No artificial nutrition or hydration | |
|Hydration | | | |
| | | Limited trial for _____ days | |
| | |Artificial nutrition and hydration | |
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